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code blue emergencies have increased in the medical-surgical setting, which revealed a lack of preparedness and proper action among medical-surgical nurses when a code blue emergency occurs. During the unfreezing stage, it is crucial to identify factors that motivate individuals toward change while also preventing loss of self-esteem (Harris et al., 2018). During the preintervention survey implementation, the code simulation was described as an opportunity to practice and grow, rather than a remediation training to encourage nurse engagement and maintain self-esteem. The change stage involves the mock code simulation training which was offered as a judgement free and open space to learn and ask questions. During this stage, individuals are offered options coupled with organizational culture change to support the implementation (Harris et al., 2018). Lastly, the refreezing stage involves incorporating the new behavior into the existing structure to return to social equilibrium (Harris et al., 2018). The recommendation following the conclusion of this project is to maintain quarterly mock code simulation in medical-surgical units to ensure that nurses maintain their code blue readiness. Project Aim The specific aim of this project was to increase self-reported nurse readiness and confidence in code blue situations through the implementation of in-situ mock code simulation. CODE BLUE: DO YOU KNOW WHAT TO DO? 9 The project took place over a fourteen-week period and changes in nurse’s self-reported code readiness were monitored with pre- and post-intervention surveys. Methods Context The 5 P’s microsystem assessment tool was utilized to assess one of the four medicalsurgical units which were studied in this quality improvement project. The B6 inpatient unit at this hospital is a 30-bed unit with eight private and 22 semi-private beds. While the unit is primarily specialized in oncology and pulmonary illness, they also care for patients with various acute and chronic illnesses such as infection, diabetes, and hypertension. The patient population includes all genders and ages over 18. This medical-surgical unit, as well as the others included in this project, has a nursepatient ratio of 1:4. Registered nurses, doctors, and certified nursing assistants make up a majority of the staff on the unit with support from the interdisciplinary teams. The unit support departments include physical therapy, occupational therapy, speech therapy, phlebotomy, lift team, dietary spiritual services, social work, and case management. The most common processes utilized on this unit include medication and chemotherapy administration, intravenous fluid replacement, telemetry monitoring, and blood glucose monitoring. Additional, less frequent processes include sepsis protocol, wound care, chest tube monitoring, and bedside thoracentesis. The process that is relevant to the implementation of this project is the protocol for code blue activation. An important component of this process is to understand the difference between a code blue and a rapid response situation. A code blue should only be activated in the case of a cardiac arrest, respiratory arrest, or unresponsive patient. When a code blue is activated, it alerts CODE BLUE: DO YOU KNOW WHAT TO DO? 10 the code blue team to get to the location of the emergency as soon as possible. Members of the code team include the first responder, doctor and critical care nurse team leaders, charge nurse, respiratory therapist, lift team, scribe, and secondary nurse. All of these people are certified in Advanced Cardiac Life Support (ACLS), while the members of the medical-surgical unit microsystem are BLS certified. Due to a lack of advanced training, the interventions that can be completed by the BLS-certified nurse prior to the code team arriving are limited but can make all the difference when it comes to patient survival. Immediate recognition and action are crucial to survival in code blue situations, which is why it is important to understand the steps that the medical-surgical nurse should take prior to the code team arriving. The B5 medical-surgical unit monitors several nursing sensitive quality indicators including patient falls, hospital acquired pressure injuries, and hospital acquired infections. Code blue situations have particularly strong impact on morbidity rates, length of stay, and ICU transfer rates. The hospital also monitors the frequency and outcomes of code blue events with a robust analysis of each event to identify areas for improvement (see Appendix C). Code blue prevention initiatives have also been implemented including the introduction of electronic Cardiac Arrest Risk Triage (eCART) in July of 2018. This tool is integrated into the electronic documentation system and uses laboratory values and vital signs to develop an early warning system for potential patient deterioration (Kang et al., 2016). The combination of prevention initiatives and outcome monitoring has been effective in identifying needs for process or equipment improvement. However, there has not been a thorough analysis of the effectiveness of nursing interventions prior to the code team arriving, which forms the basis of this project. Cost-Benefit Analysis The initial implementation of this project had no associated costs, but the associated CODE BLUE: DO YOU KNOW WHAT TO DO? 11 savings and impact on patient 

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